Provider Demographics
NPI:1962628636
Name:SUSLAK, KENNETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:SUSLAK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 PINE BROOK RD
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-0478
Mailing Address - Country:US
Mailing Address - Phone:303-817-9963
Mailing Address - Fax:303-444-0833
Practice Address - Street 1:5412 IDYLWILD TRL
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-3571
Practice Address - Country:US
Practice Address - Phone:303-817-9963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO270103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical